015601242-12-30-2021-15-AS-KHOS-CAENM8-20220106093443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601242
Report Date: 11/30/2021
Date Signed: 12/30/2021 12:07:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2021 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20210216134821

FACILITY NAME:	HEART & SOUL COMMUNITIES		FACILITY NUMBER:	015601242
ADMINISTRATOR:	TILLIS, ERICKA		FACILITY TYPE:	740
ADDRESS:	3770 SUTER STREET		TELEPHONE:	(510) 927-8046
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94619
CAPACITY:	6	CENSUS: 0	DATE:	11/30/2021
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Ericka Tillis, Administrator		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff do not follow the admission agreement regarding resident's care plan.
Facility staff demean resident’s dignity.
staff yelled at resident.
Staff do not meet resident's hygienic care needs.
Facility bathroom is not clean.

INVESTIGATION FINDINGS:

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On 11/30/2020 at 3:10PM, Licensing Program Analyst (LPA), L. Hall arrived unnanounced to deliver complaint findings.

Upon arrival LPA observed curtains closed and no vehicles at facility. LPA telephoned Adminstrator/Licensee for entry. Administrator/Licensee stated no residents are at the facility and there is not any staff avaialble at this time. LPA informed Administrator/Licensee that LPA will return at a later date.

On 12/30/2021 at 10:40AM, Licensing Program Analyst (LPA) L. Hall conducted an announced to deliver complaint findings for the above allegations. LPA met with Administrator, Ericka Tillis, Administrator

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210216134821

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEART & SOUL COMMUNITIES	FACILITY NUMBER: 015601242
	VISIT DATE: 11/30/2021

NARRATIVE

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Continued from LIC9099.

On the allegation facility staff demean resident’s dignity. During interview with RP it was stated that RP observed R1 going to the bathroom and the door was not closed. RP felt that staff should have closed behind R1. S1 stated R1 had a personal bathroom because she was the only resident at facility

On the allegation staff yelled at resident. During interview RP stated that R1 raised her voice but did not actually yell. RP also stated there was a male (unknown name) caregiver that would raise his voice. S1 stated that staff does not yell at any of the residents.

On the allegation staff do not meet resident’s hygienic care needs. During interview S1 stated that it was a couple of days before washing R1’s hair because S1 wanted R1 to get comfortable being at a new facility, but R1 was bathed every day. During interview with RP it was stated that pictures were sent ten (10) days later showing R1 had been showered. S1 stated that RP requested a picture of R1 in a towel. S1 would not comply with that request but agreed to send a picture of R1 fully clothed.

On the allegation facility bathroom is not clean. During interview with RP it was stated the bathroom was tidy, but the carpet had smudges. RP stated to LPA L. Hall that the bathroom was okay. S1 stated during interview that bathroom is cleaned every day. LPA observed bathroom to be sanitary.

LPA L. Hall was unable to interview any staff or residents due to the facility not in operation at the present time.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC9099 (FAS) - (06/04)

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